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    PATIENT UPDATED INFORMATION

    PERSONAL INFORMATION




    MaleFemaleOther







    YesNo



    PHYSICIAN INFORMATION





    DENTAL INFORMATION


    YesNo



    YesNo






    ClenchingGrindingJaw PainPopping SoundsLimited OpeningLockingSensitivity





    MEDICAL INFORMATION


    YesNo



    YesNo

    YesNo


    Local anaestheticsAntibioticsPenicillinSulfa drugsBarbituratesSedativesAspirinTylenolSleeping PillsCodeineDemerolLatex (eg. rubber gloves)

    Cardiac PacemakerTuberculosisSinusitisEmphysemaChronic BronchitisAsthmaSinus troubleStomach ulcersHepatitisHIVJaundiceDiabetesThyroid troubleAnemiaSickle Cell diseaseBlood disordersHemophiliaGlaucoma

    YesNo


    EpilepsyFainting SpellsSeizuresEmotional disturbance

    YesNo


    YesNo

    YesNo


    YesNo


    ArthritisInflammatory RheumatismBone InfectionOsteoporosisKidney troubleVenereal diseaseExposure to HIV virusAIDSTumorChemotherapyRadiation therapyCancer

    YesNo


    YesNo


    YesNo


    YesNo


    YesNo

    RESPONSIBILITY & CONSENT FORM

    I hereby authorize and request the performance of dental services for myself or any of my dependents. I also give my consent to the advisable and necessary dental procedures, medications, or anesthetics to be administered by the attending dentist or by his supervised staff for dental treatment or diagnostic purposes. These records may include study models, photographs, or x-rays. I understand and acknowledge that I am financially responsible for the services provided for myself
    or any of my dependents, regardless of the insurance coverage. I also understand that the treatment estimate presented to me is only an estimate and occasionally, the need may arise to modify treatment. I believe the information given in the previous pages of the medical and dental history to be true to the best of my knowledge.





    PATIENT UPDATED INFORMATION

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